Hospitals may soon have a more uniform set of guidance on protecting patients from ligature risk, with CMS announcing recently in a memo to state survey agency directors that it will incorporate findings from The Joint Commission Suicide Panel’s November 2017 special report on suicide prevention into its revised interpretive guidance.
CMS said it will not convene a task force on the issue, as it proposed earlier, opting instead to combine the existing guidance on ligature risk points — most commonly doors, hooks, handles, windows, belts, sheets, and towels — which could be used to attach a cord, rope, or other material for hanging or strangulation.
(The CMS memo is available online at: https://go.cms.gov/2PMBgua. The TJC suicide panel report is available online at: https://bit.ly/2j61ppl.)
Addressing ligature risk should begin with an assessment of current risks and preventive measures, and that assessment must be multidisciplinary, says Sue Andersen, PhD, CHSP, EMTP, EMSIC, national director of emergency management, environment of care and safety for Medxcel, a consulting company based in Indianapolis. She previously served as the safety director for a Level I pediatric trauma center in Detroit.
Andersen recently participated on an expert panel at the American Society for Healthcare Engineering Annual Conference and Technical Exhibition, discussing the importance of a multidisciplinary team to complete risk assessment, including assessing ligature, self-harm, and suicide risks.
“Hospitals typically put this issue on safety or facilities management because we look at it from an environmental aspect, but it’s really bigger than that. It has to do with facilities, safety, and clinical, also,” she says.
“The processes for assessing patients, reassessing patients, how to move patients, and one-to-one monitoring really come from the clinical assessment. From my experience, that has been overlooked a lot.”
The risk assessment is what truly drives change, Andersen says. Hospitals too often have tried to make improvements without first completing a thorough risk assessment, and that is partly because there is not adequate guidance on how to do so, she says.
A risk assessment is likely to find many areas ripe for improvement, and some will be straightforward alterations to the physical environment, Andersen notes.
But some of the more important findings might involve policies and procedures that are lacking or not followed consistently.
She cites the example of an at-risk patient who spends hours in the ED waiting for a transfer or inpatient bed.
Even if staff are watching the patient, what happens when staff members take that patient to the bathroom? Are staff trained on suicide risks and how to work at-risk patients? Do they have sufficient personnel to follow the established procedures?
“That is missing in many cases,” Andersen says.
“The physical alterations are pretty easy. Everyone knows that a chain or cord poses a risk, but the processes are where it can get pretty sticky. Staff often do not fully understand their roles in preventing harm related to ligature risks.”
The new CMS guidelines should provide a basis for improving hospital risk prevention related to ligatures, Andersen says.
The TJC report is helpful, but hospitals have struggled without a single, comprehensive guide for best practices, she says.
Andersen says the CMS guidance is likely to prompt many hospitals to substantially improve their ligature risk prevention.
“It will be helpful if the CMS guidance makes clear that this is the type of door you should have, this is type of one-to-one monitoring you should have. Otherwise a lot of it is subjective and left to the opinions of individuals at every hospital,” she says.
“Surveyors have so many different opinions on this, too, but it’s because we’re all working on different guidelines and no one comprehensive set,” Andersen says. “There are still some challenges that hospitals can have with this issue even when they’re trying diligently to do the right thing.”
- Sue Andersen, PhD, CHSP, EMTP, EMSIC, National Director of Emergency Management, Environment of Care and Safety, Medxcel, Indianapolis. Phone: (855) 633-9235.
