Keeping Your Patients Safe From Harm: Enacting and Sustaining a Ligature Risk Assessment

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By Scott Cormier, Vice President of Emergency Management, Environment of Care and Safety, Medxcel 

The growing concern around suicide in healthcare facilities, particularly in behavioral health units, has prompted facility managers, clinicians and governing healthcare organizations like The Joint Commission (TJC) to further assess ligature risks. Though patient suicide rates have recently been falling, TJC Journal on Quality and Patient Safety found that 49 to 65 hospital inpatient suicides occur annually. That is 49 to 65 too many. 

Your patients and your facility don’t have to become another statistic. Patient safety and wellbeing should never be ignored. Understanding ligature risks, conducting a ligature risk assessment in your facility and improving safety accordingly are all pieces of the puzzle to help eradicate suicides in a healthcare facility. 

Understanding the risks they are everywhere. 

Take a look at a standard hospital room. Note how many ligature points and potential weapons there are: door hinges, equipment, shower rods, beds, and television mounts are all common objects in patients’ rooms but could turn deadly in an instant. 

Any observable ligature risk, no matter how small, becomes an immediate Recommendations for Improvement (RFI) when observed in an inpatient psychiatric area, according to TJC. As incidents increased over the years, the federal government placed special focus on suicide, self-harm and ligature observations in hospitals and units to avoid further damage. Today, RFI must be corrected within 45 days or less depending on the severity or the total number of issues identified, and they are never appropriate for time extensions. 

Conducting a ligature risk assessment. 

Understanding the risks first is key, but the knowledge of preventing it with a ligature risk assessment takes your facility a step further to safety. A facility manager’s approach should ask three comprehensive questions: 

  1. Is the prevalence of suicide high in the area? Review the rates of suicide and behavioral health illness in the community you serve.  Understanding if the prevalence is high or low helps you determine how many ligature resistant treatment rooms you will need at your facility.  
  2. Which patients in particular are of higher risk? Patients seeking treatment at your facility should be assessed for suicide risk.  This is done as part of the clinical assessment.  Knowing how many suicide risk patients you see each year is also helpful in understanding how many safe rooms you need.  
  3. Can I put them in a safe area? Rooms can either be designed as a ligature resistant area with specialized beds, fixtures, and accessories such as sprinklers, smoke detectors, screws, and door hinges, or a regular room by have ligature points removed, either through securing ligature points through secured doors or removing equipment. Consider emergency department and inpatient areas when deploying these safe rooms.

It’s not just behavioral health units that require these assessments, especially with the new and revised TJC requirements. Psychiatric patients may pass through or spend time in non-behavioral health units like emergency rooms, so ligature risks must be addressed in those areas, too. “Any physical risks not required for the treatment of the patient that can be removed, must be removed,” states TJC. 

Improving patient safety outside of ligature removal. 

Not only do we need to ensure an environment is safe, but that the patients themselves are safe, too. It’s not simply a case of surveying a room, rather measures need to be in place to look at the bigger picture — addressing suicide. In addition to safer patient rooms, work with your facility to enact additional policies, such as: 

  • 24/7 crisis hotline with trained professionals that patients can call at any time 
  • Personalized risk management plans for each healthcare unit 
  • Guidance counseling on depression, anxiety and other mental health disorders 
  • Following up once a high-risk patient is discharged 

Ligature safety is not a clinical issue, it’s a patient issue. But just because you have your policy in writing doesn’t mean your assessments will be enacted. Your program should be living and breathing, trained often, re-evaluated and updated on a regular basis. These plans should be proactive, not reactive, and must be comprehensive within your environment of care committee. 

Given what’s at risk — people’s lives — ligature points must be understood, assessed and removed. Help ensure no patient harms him or herself under your watch. 

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About the Author

Scott Cormier is the Vice President of Emergency Management, Environment of Care (EOC) and Safety at Medxcel, specializing in facilities management, safety, environment of care, and emergency management and provides healthcare service support products and drives in-house capabilities, saving and efficiencies for healthcare organizations that, in turn, improve the overall healing environment for patients and staff. Cormier leads the development and implementation of emergency management, general safety and accident-prevention programs for the national network of hospitals that Medxcel serves. 

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