The Lowdown on Behavioral Healthcare and Ligature-Resistant Locks

Published: February 2, 2018

Hospital, schools and universities are on the forefront of dealing with mental health issues. We live in a society where anxiety is far more prevalent than in the past, and we need to incorporate this knowledge into our general medical care environments.

Our medical intake facilities are well-prepared for patients who are at risk of spreading diseases that can harm others. Medical staff are trained how to incubate and isolate patients to prevent an escalation. Special medical equipment is in place and procedures are documented for these occurrences.

Mental health is now being recognized as a discipline that is not exclusive to behavioral healthcare wards. The Center for Medicare and Medicaid Services (CMS) has recognized the frequency and severity of mental health issues and the alarming increase in loss of lives. As a result, they have made this a priority and expect medical facilities to take note and adjust their policies and procedures as well as their physical plant to help combat this crisis. The Joint Commission also understands the importance of this issue.

I’ve brought up the supremacy and importance of CMS and Joint Commission guidelines because the intake process for an at-risk patient should now follow an established protocol, closer to an incubation admittance than the process for a standard patient.

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At-Risk Patients Require Special Accommodations

The design of the evaluation and waiting room for patients seeking behavioral healthcare services must protect patients from harming themselves as they await evaluation and admittance. The phrase for door hardware and other elements in this safe environment is “ligature-resistant.” Literally, it means the design of products and elements that prevent the tying of an object onto it to harm oneself. The original term was “anti-ligature,” but the newer term is more indicative of the goal.

Ligature-resistant products include a wide variety of items, from grab bars to shower heads to door locks. Complicating the design is the need to comply with the Americans with Disabilities Act (ADA). This means that pinching and grasping to operate a faucet or doorknob is not compliant. There are guides that list and in some cases rate a variety of ligature-resistant products.

Two continuously revised guides are The Design Guide for the Built Environment of Behavioral Health Facilities and Patient Safety Standards, Materials and Systems Guidelines Recommended by the New York State Office of Mental Health (Commonly referred to as the NY State OMH Guide).

The authors of both documents take great care to include products and commentary to assist in the effective design of behavioral health spaces. The Veteran’s Administration (VA) also publishes a guide for use by those designing VA facilities. They cover the importance of design in supporting the goal of creating a healing environment for patients. Behavioral healthcare wards 10 years ago relied upon hardware designed for prisons. Today, there are many choices out there that help a ward resemble a Marriott as opposed to a correctional facility.

Ligature-Resistant Design Can Be Confusing

All of the guides state that use of their suggestions is voluntary, and designers and facility managers should use their best judgment regarding which elements to use. Similarly, the Joint Commission does not publish guidance identifying specific products or solutions. It is up to the facility to determine what they should be using to satisfy the surveyor.

Needless to say, this can be confusing for architects, specifiers and facility staff. Best practices can change from one facility to another, and the layout of a ward can affect the types of materials to be used. Similarly, a clinic or emergency room that designates an area for at-risk mental health patients will have different challenges than a full ward.

Let’s look at one area that needs to be addressed in every case: the door. Anecdotal evidence points to it being a major area of concern. Ligature-resistant door locks, hinges and alarms have been created to mitigate the risk.

Traditional knobs and levers are not suitable for this environment. Knobs, besides being easy targets for tying onto, are not ADA compliant. Levers, especially rigid ones, are major risks. Previously, facilities used detention facility door locks with a conical, spherical design with detents for grasping as the basic product to provide ligature resistance. These products were hard to grasp, even by able-bodied users and violated ADA because they required pinching and grasping.

The first ligature-resistant lever locksets were introduced in 2008, a watershed year for ligature-resistant locking. These levers were never rigid (even when the door was locked) and their special angular design and tapering successfully met the criteria to prevent tying on.

More recently, additional locks have been produced by a variety of manufacturers. Some are within the lever category, while others are larger units that replace the lever with a larger, closed design, meaning the space that would normally exist between the back of the lever and the door it covered. Products are available in a wide variety of functions and in both mortise and cylindrical lock designs.

Other door hardware developed for use in these applications is the rescue strike plate. Patient doors normally swing into the room. To prevent a patient from barricading themselves in the room, a special hinge arrangement is used and strike plate installed that allows the door to swing in the opposite direction (into the corridor) in the event the patient blocks the inward opening door.

Tops of Doors Pose Risks as Well

The next area of concern became the top of the door. Doors always swing away from the frame while opening and back into the frame upon closing. Tying a knot in the bedsheet and throwing it over the door and then closing the door became a greater risk. Facilities begged for a solution.

Over-the-door alarms became the next area of innovation. Various products exist, which detect an object draped over the door and/or wedged between the bottom of the frame header and the door. These systems contain elements to detect and notify. Elements include:

  • A pivoting sensor bar across the top of the door to detect an object
  • A custom hinge that is ligature-resistant and aids in reducing the hazardous gap between the door edge at the hinge side and the frame
  • A strobe mounted in the hallway outside each patient room door to alert staff as to the exact location of someone trying to harm themselves
  • A keyswitch at the side of the door for resetting an alarm that requires a presence at the door or room that triggered the alarm
  • A controller and nurses station console to alert someone in the nurse’s station of an event or an alarm.

Some patient rooms have an individual or shared bathroom within the room. In this case, the inner bathroom door would receive a sensor bar and hinge, and would then be connected via a splice box in series with the patient room entry door. Only one keyswitch and strobe would be needed per room.

One of the newest developments, designed to meet the Joint Commission’s focus on patient safety during the admission process or at a standalone clinic, is the single door patient door alarm kit. These kits recognize that the corridor is not a ligature resistant area and that a facility would not have the same type of nurse’s station as a behavioral healthcare ward. The controller and nurses console have been eliminated. In their place is a single enclosure with strobe and siren, which connects to the keyswitch via an armored cable for easy installation. These single door kits assist facilities in meeting the demand for a safe haven for at-risk patients awaiting evaluation or admission.

Campuses need not fear the effort to meet the CMS directive and Joint Commission focus. There are ways to safeguard lives in a cost-efficient manner.

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Strategy & Planning Series
Strategy & Planning Series
Strategy & Planning Series
Strategy & Planning Series