According to reports gathered in Joint Commission’s Journal from November of 20181, ~70 percent of suicides in hospitals were by a means of hanging. As a response, the Joint Commission and other behavioral health organizations have created reports on this trend and created policies to reduce and prevent the potential for suicides these facilities face with an expressed focus on ligature-resistant areas.
Ligature-resistant hardware in mental and behavioral health spaces is not just recommended but an integral part in scoring well in a Joint Commission certification audit. As stated in the recommendations the Joint Commissions set on Inpatient Psychiatric Units it is required, “Inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, must be ligature-resistant…2”
Areas described by this requirement include (but are not limited to):
- Patient rooms
- Transitional areas
- Common patient care areas
Covering these areas with ligature-resistant products can include a variety of product types focused on everything from servicing doors, door hardware, and door accessories to a number of surrounding functions.
|Product Type/Location||Product Manufacturer||Security Features|
||The Door Switch
Over the Door Alarm
||ASSA ABLOY, Corbin Russwin, BEST Access,
Schlage, Marks USA
Examining the Suicide Trend
The Center of Disease Prevention and Control (CDC) found in a 2016 report that suicide is the 10th-leading cause of death in the United States3—an alarming statistic. The CDC’s report gets noted in The Joint Commission’s complimentary publication R3 Report | Requirement, Rationale, Reference4 as a provocation to re-evaluate the National Patient Safety Goal (NPSG) to address suicide prevention.
As mentioned earlier, The Joint Commission’s Journal released a report in November of 20181 producing estimates from the collected data of hospitals reporting to the National Violent Death Reporting System (NVDRS) 2014–2015, and The Joint Commission’s Sentinel Event (SE) Database from 2010 to 2017. Data from this report implicates the larger statistical role a door’s ligature points perform in suicides committed by psychiatric patients in behavioral health facilities.
Within the SE Database, of the 137 inpatient hanging events, a ligature fixture point was identified in 106 cases—a door, door handle, or door hinge was the most commonly used fixture point (53.8%). Hanging was the most common method of inpatient suicide in the NVDRS and SE databases, accounting for 70.5% of all inpatient suicide events. Of the inpatient hanging events, a door, door handle, or door hinge was the most commonly used fixture point (53.8%).1
The implications of each of these reports indicate the need for an escalated approach to suicide prevention and the role doors (and ligature-resistance) play in reducing suicide prevention.
Handling Door Hardware and Accessories in Mental and Behavioral Health
Diana Oller, the Executive Director of The Door Switch, spends a great deal of time on the road educating behavior healthcare facilities of what goes into preventing suicides onsite. In an article for Door Security + Safety, Oller writes about the benefits of ligature-resistant hardware in combating patient suicides.
In Oller’s article she describes how The Door Switch is designed to mitigate ligature points associated with the top-of-the-door and door hinges. The Doors Switch’s standard retrofit application is a full-surface continuous hinge application. The full surface hinge allows flexibility for doors currently equipped with 3-butt hinge or full mortise continuous hinge applications. These applications are retrofit applications and usually maintain the facility’s original design by utilizing the existing doors.
The Door Switch’s Over the Door Alarm is available in a double-swing hinge and electrified pivot applications to provide a barrier-resistant application. In addition, a full mortise continuous hinge application is available. For more details: See The Door Switch.
In laymen’s terms, this indicates The Door Switch is designed to play a central role in door and door hardware ligature resistance on more than one front—addressing the ligature point at the top of the door and those at the door’s hinges.
Doors in Mental and Behavioral Health: Fact and Fiction
James M. Hunt, AIA, NCARB is a behavior healthcare facility design consultant with experience as a practicing architect and facility management professional. In Hunt’s 2015 article for the Academy of Architecture for Health (AAH) he assesses suicides committed by use of a ligature point on a patient’s room doors and frames “remain a frequent occurrence” 5 in behavioral healthcare facilities. Hunt hints at the availability of alternative door hardware that address door and door hardware ligature points as viable options to combat these unfortunate occurrences.
“There are safety alternatives available including pressure sensitive or electric eye type devices that mount on door edges, connect to a central alarm system, and sound alarms when they are activated by the presence of an object, such as a ligature.”5
In regard to tight-fitting doors that create a risk for ligature attachments Hunt asks, “Is it acceptable to ignore a known serious hazard just because it’s required by code and ‘everyone else is doing it?’”
Next Steps for Your Mental and Behavioral Health Facility
In conclusion, any department where psychiatric inpatients are being cared for requires a keen eye for the clearing of all possible ligature points and/or are nullified by the best choice of safety-alternative, ligature-resistant hardware and accessories. Contact your local IDN branch to speak with an informed sales team or to schedule a consultation visit from one of our expert sales representatives to determine the best hardware for your facility and situation.
- Williams, Scott C. et al. (2018). Incidence and Method of Suicide in Hospitals in the United States.
Joint Commission Journal on Quality and Patient Safety, 44(11), 643-650.
Retrieved from https://www.jointcommissionjournal.com/article/S1553-7250(18)30253-8/fulltext.
The methods used in the inpatient setting to commit suicide were similar in the two databases (Table 5). Hanging was by far the most common method of inpatient suicide in the NVDRS and SE databases (33 of 46 [71.7%] and 137 of 195 [70.3%], respectively). The location and ligature fixation point for hangings were consistently coded in the SE Database but not in the NVDRS. A total of 99 of 195 (50.8%) sentinel event suicides occurred in the bathroom, 66 (33.8%) in the bedroom, 8 (4.1%) in the closet, 7 (3.6%) in the shower, and 15 (7.7%) in another location. Within the SE Database, of the 137 inpatient hanging events, a ligature fixture point was identified in 106 cases—a door, door handle, or door hinge was the most commonly used fixture point (53.8%). Hanging was the most common method of inpatient suicide in the NVDRS and SE databases, accounting for 70.5% of all inpatient suicide events. Of the inpatient hanging events, a door, door handle, or door hinge was the most commonly used fixture point (53.8%). Not surprisingly, more than 90% of suicides took place in private spaces such as the bathroom, bedroom, closet, and shower.
- Special Report: Suicide Prevention in Health Care Settings Recommendations Regarding Environmental Hazards for Providers and Surveyors. (2017). The Joint Commission Perspectives®, 37(11), 3-5.
Retrieved from https://www.jointcommission.org/assets/1/6/
- Heron, M., Ph. D. (2018). Deaths: Leading Causes for 2016. National Vital Statistics Reports, 67(6), 9-9. Retrieved from https://www.cdc.gov/
- Ligature Risks – Assessing and Mitigating Risk for Suicide and Self-Harm. (n.d.). Retrieved from https://www.jointcommission.org/
Ligature Risks – Assessing and Mitigating Risk for Suicide and Self-Harm
What are the Joint Commission expectations for identifying and managing ligature risks in the hospital setting?
Element of Performance # 1 states “Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided”. Therefore, ligature and self-harm risks must be identified and eliminated.
- Hunt, James M. (2015). Behavioral Healthcare Design: Ten Things You ‘Know’ That ‘Just Ain’t So’. The Academy Journal of the AIA Academy of Architecture for Health (AAH), 17, 4-11. Retrieved from https://www.brikbase.org/sites/default/files/
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Kwame Shorter is the Digital Communications and Website Specialist at IDN, Inc.