Here’s why and how all hospitals, emergency rooms and behavioral health facilities should conduct ligature risk assessments.

Today’s hospitals and behavioral health facilities must ensure all ligature and self-harm risks are identified and reduced as much as possible. For these efforts to succeed, leadership and staff must be educated about what the potential risks look like and how to eradicate them—and whether certain equipment that could be dangerous, such as medical beds with side rails, is actually necessary for safe treatment.

“The organization must consider these risks in patients’ overall suicide/self-harm risk assessments, then implement appropriate interventions to diminish those risks,” The Joint Commission (TJC) points out.

What Is Ligature Risk?

Health Facilities Management writes that individuals who are considering suicide or self-harm are at a greater risk of harming themselves if there are convenient “ligature-risk points” in their environment. It goes on to further define ligature risks as “anything that can be used to attach a cord, rope or other material for hanging or strangulation, including ceiling pipes, shower rails and radiators.”

The New England Healthcare Engineers’ Society (NEHES) defines a ligature point as a fixed point that a ligature can be tied to, wedged around (or behind), or held in place by any means that enables the ligature to bear the weight of the patient—either wholly or partially.

Health Facilities Management points out that the vast majority of inpatient suicides have resulted from hanging, most commonly in a bathroom or bedroom and often using a door or its handle or hinge; a head, handle, bar or door in the shower; a ceiling or sink pipe; or another type of fixture as the ligature fixation point.

To minimize these occurrences, develop a checklist around a thorough inspection of all patient rooms, bathrooms and other spaces occupied by patients. Be sure to examine all light fixtures, air grills, doorknobs, or other potential ligature risks. TJC has created a free checklist for suicide prevention.

The same level of detail should be used when assessing emergency rooms, where most behavioral health patients are located before being medically cleared for repositioning to the hospital’s behavioral health zone. For example, some facilities are developing “preferred behavioral areas.” These safe environments are free of certain types of medical equipment and other hazards that individuals could use to hurt themselves. 

A Focus on Ligature-Resistance

According to the American Society for Healthcare Engineering (ASHE), ligature-resistant means lacking points where a cord, rope, bed sheet or other material can be looped or tied to fashion a point of attachment that may lead to loss of life or self-harm. Certain areas of a hospital—and specific “sub-areas” within those rooms or spaces—pose the biggest threats.

For healthcare providers, the areas of facility where patients spend the most time alone—often the patient room or bathroom (half of hospital suicides occur in the latter)—pose the greatest risk for self-harm. Healthcare organizations can refer to the Facility Guidelines Institute (FGI) for more guidance on this issue.

Along with patient rooms and bathrooms, the FGI’s guidelines call out common patient areas, corridors or any other rooms that are not continuously monitored by hospital personnel. Within those areas, all doors, handles, hooks, windows, sheets, towels and belts should be assessed for potential risks and/or removed completely.

In areas where patients receive care, FGI says healthcare organizations should be particularly aware of ligature points like equipment or furniture where material can be “wrapped around”—even those that may be low to the ground and not historically considered a place where patients can hang or otherwise hurt themselves.

The 3-Point Approach to Prevention

In 2018, ASHE published a checklist of potential ligature points that hospitals can use to evaluate their facilities. In Three-Step Ligature Risk Guidance for General Acute Care or Emergency Departments, the organization outlines the following approach for managing ligature risks and preventing patient self-harm in general acute care or emergency departments (please note: these steps do not apply for psychiatric units):

Step 1: Identify. Identify patients who are currently at risk for intentional harm to themselves or others (steps two and three need only be taken with patients who are identified as potential risks).

Step 2: Observe. Provide one-to-one monitoring of at-risk patients with continuous visual observation. The person observing the patient needs to be able to intervene immediately, ASHE points out, noting that video observation is not appropriate since the video monitoring process cannot provide immediate intervention. The organization tells health care organizations to conduct careful reviews of the rules and regulations that apply to their specific facilities.

Step 3: Remove. In any cases where one-to-one continuous observation is not feasible, hospitals must remove or clinically mitigate all environmental risks. Loose items should be removed from the patient area. Fixtures installed in the room do not need to be removed, ASHE states, however, patient access to certain areas may need to be restricted to prevent patients from reaching items that they could use for self-harm.

Assessing the Risk

It’s been more than two years since TJC first announced that it would be placing new emphasis on ligature attachment points in facilities and imposing strict penalties for non-compliance.  

This is something that hospitals need to be aware of. In fact, ligature risk in healthcare settings is an evolving matter than must be monitored and kept up with. For assistance, healthcare organizations can visit TJC’s online portal, refer to the FGI Guidelines, and read the Centers for Medicare & Medicaid Services (CMS) regulations.   

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