Preventing Inpatient Self-Harm with Three-Step Ligature Risk Guidance

Wednesday, January 9, 2019
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From 2010 to 2014, The Joint Commission reported more than 1,000 suicides occurring among patients receiving care in a staffed health care setting or within three days of discharge.

The Need for Facility-Wide Attention
A common misconception holds that only dedicated behavioral health and psychiatric units need to be concerned with mitigating the risks associated with inpatient suicide, when in reality, non-dedicated spaces, both inpatient and outpatient, service at-risk patients. According to a recent Centers for Disease Control and Prevention report, 54% of those who commit suicide do not suffer from a mental health condition. Entire facilities and all staff members should be committed to suicide prevention and risk control.

Identify, Observe, Remove
Hospitals and health care systems can use a three-step approach to mitigate ligature risks and prevent patient self-harm in general acute care and emergency departments.

Step 1: Identify
Medical staff should take the necessary steps to identify patients who are at risk for self-harm.

Hospitals and health care facilities have the opportunity to play an active role in preventing suicide through multi-factorial suicide screenings and follow-up after positive screens. All staff members should use the same evidence-based screening tool to collect information about the patient’s past and present thoughts of self-harm. The screening process should be brief and should include specifically asking the patient if they have had thoughts of suicide.

Step 2: Observe
When a suicide screening result is positive, health facilities should provide 1:1 continuous monitoring for those patients.

Completely removing ligature risks isn’t always possible nor is it the best or the only option. The priority should be 1:1 continuous observation of any at-risk patient. Facilities should be designed to accommodate 1:1 continuous monitoring with 360-degree viewing and a paid sitter should be present with the patient at all times. Because the person observing needs to be able to intervene immediately, video observation should not be an option.

Step 3: Remove
If 1:1 continuous observation is not possible; health facilities should attempt to remove all potential risks from the physical environment.

Sometimes continuous observation is not feasible. For example, some states require that patients be left alone when using the bathroom. In these cases, facilities should make every possible attempt to identify and remove risks, which may include restricting access to certain areas. The Patient Safety and Ligature Risk Checklist is an ASHE resource that lists potential ligature points and other self-harm concerns categorized by room.

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