Suicide Risk: Ligature & New TJC Safety Goal

(1/14/2019)

The holidays are over, so we’re settling into the winter doldrums before spring returns. While some may think we’re moving away from the season where suicides are prevalent, suicide rates actually peak in springtime, rather than winter. According to Neel Burton, M.D., “This is probably because the rebirth that marks springtime accentuates feelings of hopelessness in those already suffering with it.”

It unfortunately remains that suicide is the 10^th leading cause of death and is declared among the top three sentinel events by The Joint Commission (TJC). It’s not just those who are alone – 1,089 suicides occurring from 2010–2014 were among patients receiving care in a staffed, around-the-clock care setting or within 72 hours of discharge.

Suicide rates are not diminishing, and they occur within healthcare environments. That is why TJC placed a special focus on suicide, self-harm and ligature observations in psychiatric hospitals and units in March 2017, and in December 2018, it announced revisions to its National Patient Safety Goal (NPSG) that address “suicide prevention to improve quality and safety of care for patients treated for behavioral health conditions and those identified at high risk for suicide.” These changes are set to take effect on July 1, 2019.

These are the top three things you need to know about NPSG 15.01.01 - Reduce the risk for suicide:
 

1. Know the New & Revised Requirements

Accreditation requirements are updated regularly. It’s imperative that accredited hospitals and systems remain aware of changes to remain compliant and be continually survey-ready. TJC’s new and revised requirements address:
 

• Environmental risk assessment and action to minimize suicide risk
• Use of a validated screening tool to assess patients at risk
• Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation
• Documentation of patients’ risk and the plan to mitigate
• Written policies and procedures addressing care of at-risk patients, and evidence they are followed
• Policies and procedures for counseling and follow-up care for at-risk patients at discharge
• Monitoring of implementation and effectiveness, with action taken as needed to improve compliance

All of these are vital for facilities managers to incorporate into their hospitals, though the first one is especially notable for physical spaces.
 

2. Ligature Risks are Everywhere

Take a look at a standard hospital room. Note how many ligature points – and potential weapons – there are. When TJC placed special focus on suicide, self-harm and ligature observations in psychiatric hospitals and units in 2017, any observable ligature risk, no matter how small, became an immediate Recommendations for Improvement (RFI) when observed in an inpatient psychiatric area. RFI must be corrected within 45 days or less depending on the severity or the total number of issues identified. Given what’s at risk — people’s lives — ligature RFIs are never appropriate for time extensions according to TJC. It’s not just psychiatric units or buildings that require these assessments, especially with the new and revised TJC requirements. Psychiatric patients may pass through or spend time in nonbehavioral health units like emergency rooms, so ligature risks must also be addressed in those areas. “Any physical risks not required for the treatment of the patient that can be removed, must be removed,” states TJC, and patients should remain under surveillance if risks remain in the environment.
 

3. A Continuous Assessment

Although springtime may see heightened rates of suicide, it doesn’t mean facilities can relax once summer hits. When it comes to risk assessments within your hospital, it should never be viewed as a onetime procedure. After an initial assessment of the new TJC requirements is complete, it is important to establish ongoing risk assessments to ensure any updates to regulations are being followed and there are no new potential risks that surface over the course of the weeks, months and year.

If you want more information about developing tools for efficient risk assessments, download our white paper on addressing ligature and suicide risks in healthcare facilities. Need a more hands-on approach? Contact us to see how Medxcel can help your facility.