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Joint Commission Gives Patient Suicide Prevention Tips to Hospitals

The guidance addresses some of the more contentious issues relating to patient suicide prevention and mitigation in hospitals.

The Joint Commission issued a report on patient suicide prevention and mitigation Oct. 25.

The latest suicide prevention guidance came after the Joint Commission gathered data from healthcare organizations on suicides that occurred in their facilities and then brought together officials from provider organizations, suicide prevention experts, behavioral health designers, Joint Commission surveyors and staff, and members of the Centers for Medicare & Medicaid Services (CMS).

The guidance states that an average of 85 suicides have been reported as sentinel events to the Joint Commission over the last five years. It also acknowledges that in some circumstances, the Joint Commission and state agencies have disagreed on patient suicide prevention and mitigation strategies and on what constitutes a ligature risk.

“There needs to be consensus on these issues so that health care organizations will know what changes they need to make to keep patients safe and so surveyors can reliably assess organizations’ compliance with standards,” the guidance reads.

The newest recommendations in the guidance address only the “most debated and contentious issues related to environmental hazards” impacting suicide. They are summarized below.

Suicide Prevention in Inpatient Psychiatric Units

The latest guidance gave eight recommendations for inpatient psychiatrist units, or IPUs. All recommendations apply to both psychiatric hospitals and general acute care settings.

  1. IPUs must be “ligature-resistant” in patient rooms, patient bathrooms, corridors and common patient areas. The panel defined ligature-resistant as areas, “Without points where a cord, rope, bedsheets, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or suicide.”
  2. The doors in IPUs located between patient rooms and hallways must contain ligature-resistant hardware including hinges, handles and locking mechanisms.
  3. Hospitals should not be required to have risk mitigation devices installed in IPUs that decrease the chances the top of a corridor door will be used as a ligature attachment point.
  4. In IPUs, the transition zone between patient rooms and patient bathrooms must be ligature-free or ligature-resistant.
  5. IPU patient rooms and bathrooms must have a solid ceiling (a drop ceiling is not an acceptable alternative).
  6. In IPUs, drop ceilings can be used in hallways and common patient care areas as long as all aspects of the hallways are fully visible to staff and there are no objects that patients could easily use to climb up to the drop ceiling, remove a panel, and gain access to ligature risk points.
  7. In IPUs, medical needs and the patients’ risk for suicide should be carefully assessed and balanced to determine the optimal type of patient bed to meet both medical and psychiatric needs. If patients require medical beds with ligature points, appropriate mitigation plans and patient safety precautions must be in place.
  8. Standard toilet seats with a hinged seat and lid are not a significant  risk for suicide attempts or self-harm; they should not be cited during surveys and do not need to be noted on a risk assessment.

Suicide Prevention in General Acute Inpatient Settings

The panel determined that the general medical/surgical inpatient setting does not need to meet the ligature-resistant standards of an IPU.

The panel noted patients admitted to medical/surgical inpatient settings with serious suicide ideation often require equipment for monitoring and treatment, making it impossible to make their environment truly ligature-resistant.

If patients are admitted to general acute inpatient settings with suicide ideation then all objects posing a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care should be removed. Mitigation strategies should also be put into place and documented, including one-to-one monitoring, careful assessment of objects brought into the room by visitors, and protocols for transporting patients to other parts of the hospital.

The Joint Commission will cite ligature risk in a general acute patient setting if the healthcare organization cannot demonstrate that all of the following are routinely achieved:

  • Training and competency testing staff on how they would address the situation of a patient with a serious suicidal ideation
  • One-to-one monitoring of patients with serious suicidal ideation
  • Risk assessments for objects posing a risk for self-harm and identifying objects that should be routinely removed from the immediate vicinity of patients with suicide ideation who are being treated in the main area of the emergency department
  • Removing items that a suicidal patient could use for self-harm
  • Monitoring of visitors
  • Monitoring of bathroom use for a patient with serious suicide ideation
  • Protocols to have qualified staff accompany patients with serious suicide ideation from one area of the hospital to another

Suicide Prevention in Emergency Departments

The panel determined emergency departments do not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment.

Similar to patients in medical/surgical settings, patients in emergency departments often require medical equipment for treatment and monitoring, making it impossible to make their environment truly ligature-resistant.

Still, there are two main strategies to keep emergency department patients at risk of suicide safe. The first is to place the patient in a “safe room” that is ligature-resistant or that can be made ligature-resistant by having a system where fixed equipment can be excluded from the patient care area.

The second strategy is to keep the suicidal patient in the main area of the emergency department, continuously monitor them one-to-one, and remove all objects that pose a risk for self-harm that can be easily removed without impacting medical care.

The Joint Commission does not mandate “safe rooms” in emergency departments, but healthcare organizations should have policies, training and monitoring systems in place to ensure the two strategies outlined above are done properly.

Additionally, suicidal patients must be placed under demonstrably reliable monitoring that is linked to the provision of immediate intervention by a qualified staff member when called for. Healthcare organizations should have a policy including this detail, and they should also do all of the following to prevent patient suicides:

  • Screen all patients with psychiatric disorders for suicidal ideation (NPSG 15.01.01)
  • Assess the risk of a suicide attempt among suicidal patients
  • Conduct a risk assessment for objects posing a risk for self-harm and identify those objects that should be routinely removed from the immediate vicinity of patients with suicidal ideation in the main area of the emergency department
  • Have a protocol for monitoring suicidal patients, including the use of bathroom, and how to ensure visitors don’t bring objects that suicidal patients could use for self harm
  • Have a protocol for qualified staff to accompany suicidal patients moving areas of the hospital
  • Train and test staff on how to respond to a suicidal patient

For more Joint Commission directives and guidance on patient suicide prevention, see Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings.

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