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Doors and videos: TJC offers more ligature prevention clarification


July 1, 2019

Apparently, The Joint Commission (TJC) thought that hospitals haven’t gotten the message about ligature prevention.

In a Q&A piece in the May Perspectives issue, The Joint Commission clarified key requirements surrounding facility improvements and design that some hospitals have been confused about. Specifically, it appears that some facilities have been confused about the requirements for locked doors as well as video monitoring of potentially suicidal patients.

“The Joint Commission convened the Suicide Risk Reduction Expert Panel in 2017 and 2018 to provide guidance to customers and surveyors on safeguards to prevent suicide,” the article in Perspectives said. “Since then, it has released risk reduction recommendations from the panel’s discussion of issues related to prevention of suicide in health care settings as well as frequently asked questions about those recommendations.”

The issue goes back to February 2016, when The Joint Commission issued Sentinel Event Alert #56: Detecting and treating suicide ideation in all settings as a way of bringing attention to the problem. Suicide is the 10th leading cause of death in the United States, taking more than 40,000 lives a year. The most recent data published by the National Violent Death Reporting System reveals that, in 2015, 83 suicides occurred in medical facilities.

Hospitals must do a better job not only of identifying and monitoring patients at risk of suicide, but of removing the means to accomplish suicide in the physical environment.


In 2016, The Joint Commission ordered its surveyors to immediately place more emphasis on suicide prevention in hospitals, with close attention paid to the assessment of potential ligature (hanging) injuries, suicide, and self-harm monitoring—especially in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.

The added emphasis comes at a time of national concern about suicides and was meant to coordinate with the “Zero Suicide” campaign, according to Joint Commission literature. The campaign is a joint effort between several national outreach groups trying to eliminate suicide in healthcare facilities nationwide.
On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are being provided a safe and appropriate environment.

Video monitoring

It’s an obvious requirement that hospitals monitor patients with a high risk of suicide; the question is what constitutes proper monitoring. The Joint Commission has received many questions about whether hospitals can use video monitoring or so-called “electronic sitters” as an alternative to having a human monitoring the patient.

The Joint Commission’s answer: No.

“For patients identified as high risk for suicide, constant 1:1 visual observation should be implemented (in which a qualified staff member is assigned to observe only one patient at all times),” the Perspectives article says. “This allows the assigned staff member to immediately intervene should the patient attempt self-harm. The use of video monitoring or electronic sitters is not acceptable in this situation because staff is not immediately available to intervene.”

The Joint Commission further clarifies that video is acceptable as a complement to one-on-one monitoring, not as a stand-alone replacement. In other words, an actual human must be available to intervene at a moment’s notice should a patient attempt suicide. A video monitor will not necessarily be able to discern that danger quickly enough to alert staff members, who may be otherwise distracted.

That said, there are exceptions—for example, if the patient may pose a safety risk to staff.

“Video monitoring should be used only in place of direct line-of-sight monitoring for patients at high risk for suicide when it is unsafe for a staff member to be physically located in the patient’s room,” says the article. “In addition, for both direct line-of-sight and video monitoring of patients at high risk for suicide, the monitoring should be constant 1:1 at all times (including while the patient sleeps, toilets, bathes, and so on), and the monitoring must be linked to immediate intervention by a qualified staff member when required.”

Bottom line: Whenever possible, make it protocol to have an actual human watching a patient deemed a high risk for suicide. In situations where you may use video, make sure an actual human is watching the video closely and is ready to intervene immediately.

Locked door requirements

When The Joint Commission says it wants locked doors in inpatient psychiatric units, the meaning might seem like common sense. But there appears to be quite a bit of confusion about the difference between “self-locking” and “self-closing” doors.

Up until now, Joint Commission requirements for doors and corridors in these units included the following:

  • Doors between patient rooms and hallways must contain ligature-resistant hardware, which includes, but may not be limited to, hinges, handles, and locking mechanisms.
  • In both psychiatric hospitals and general/acute care settings, healthcare organizations should not be required to have risk-mitigation devices installed to decrease the chance that the top of a corridor door will be used as a ligature attachment point. Noted was the fact that there are devices on the market to stop this risk, including lasers, pressure plates, and cameras. A factor in this recommendation appears to be the limitations of these devices, including the possibility of false alarms that could distract staff and provide an opportunity for a patient to attempt suicide.
  • Hospitals instead will be required during surveys to note such doors on their environmental risk assessments and describe their mitigation strategies, such as appropriate rounding and monitoring by staff.
  • In both psychiatric hospitals and general/acute care settings, the transition zone between patient rooms and patient bathrooms must be ligature free or ligature resistant. Note that this can be done with mechanical means, such as by removing the door, using alarms, or using doors with angled top edges. Many hospitals use behavioral means such as denying access to the bathroom unless staff is present, but these approaches still require a ligature-resistant door.

The Joint Commission’s answer to some of the questions it has received is that surveyors expect both self-closing and self-locking doors to separate areas required to be ligature resistant from those that are not. The idea is to eliminate human error factors.

“The intent is to eliminate any staff reliance on closing or locking those doors to prevent patient harm,” the Perspectives article says. “In addition, devices to hold open a self-closing and self-locking door are prohibited (such as magnetic hold-open devices, door wedges, and so on). The door should self-close and self-lock to prevent free access by patients into the space that is not required to be ligature resistant.”

According to Steve MacArthur, a safety consultant for the Greeley Safety Consultant, Danvers, Massachusetts, and author of the blog “Mac’s Safety Space,” the clarifications apply to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, and consult rooms.

“I can’t say that I am surprised (about the clarification) as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (‘Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.’) as it was probably a little too all-inclusive,” he says.

Other guidance

If you are looking to make some changes to your facility to help cut down on suicide risk, there is no shortage of advice out there. The Joint Commission recommends the Design Guide for the Built Environment of Behavioral Health Facilities, published by the Facility Guidelines Institute (FGI). In addition, the design guidelines published by the International Association for Healthcare Security and Safety (IAHSS) have lots of information on helping to prevent patient suicides and harm.

You can also access a Joint Commission suicide prevention portal, with all the information hospitals need, at www.jointcommission.org/topics/suicide_prevention_portal.aspx.

CMS likely to revise SOMA on ligature risk requirements

Expect CMS to be making changes to sections of Medicare’s State Operations Manual (SOM), Appendix A, on ligature risk and suicide prevention after soliciting comment on proposed revisions in April to the manual of interpretive guidance for state surveyors.

The revisions may also include the section of the SOM describing the process of handling facility requests for a time extension to take corrective actions.

In Quality, Safety and Oversight Group memo, DRAFT-QSO-19-12-Hospitals, CMS acknowledged that corrective actions can include extensive renovations that take time and require capital budget requests that cannot be done within the normal 60 days mandated for correcting deficiencies related to the Conditions of Participation (CoP).

The average cost to implement ligature risk requirements for a 100-bed psychiatric hospital estimated at $3,462 a day, according to a recent report commissioned by the National Association for Behavioral Healthcare (NABH), The High Cost of Compliance. Physical renovations and equipment purchases, meanwhile, were running an average of “more than $12,700 per psychiatric bed,” according to the report.

For more on the proposed revisions and the NABH report, see the May 20 issue of Environment of Care Leader, an archive of which can be now found online at hospitalsafetycenter.com.


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